Saturday, May 31, 2008

Babies are born into this world into different situations, and while most babies are born into loving families, the range of parents is amazing. Some parents have special "birth plans" and pediatrician appointments already established before the baby even leaves the hospital, while other babies need Child Protective Services (CPS) because the mom's living situation is unsafe or unstable.

Baby M was a small baby girl born during my second day of service in the newborn nursery, the daughter of a mom who told Jim, the intern, that she had used drugs, smoked a pack a day, and injected an IV "speedball" (cocaine and heroine) during her pregnancy. The situation was not unusual, but it naturally made the hospital staff a little concerned. Dad was in prison, mom was acting a little strange, and it was unclear whether mom would be able to take care of Baby M.

CPS offered to check mom into a residential rehab facility so that she could live with her baby, but mom was upset about not being able to take care of a dog at home. Since mom's urine tox tested positive for methamphetamines, and so did Baby M's, the staff decided to keep the baby in the nursery until mom detoxed a little. Usually, babies stay with their moms in the hospital rooms in order to promote bonding. Gone are the days when u see babies lined up in little rows behind a glass window, the newborn nursery is usually a quiet place when no circumcisions are occurring (just kidding).

Jim, the compassionate intern, urged that Baby M stay with mom to encourage bonding. Maybe spending time with her baby would convince mom to take CPS's offer of a second chance. Disappointingly, mom didn't seem to be interested in taking care of Baby M...who spent the same amount of time in the nursery as before.

Whenever we saw Baby M -- small, quiet, with a rounded nose -- sleeping in her crib alone in the newborn nursery -- I would look at Jim with a funny expression and he would shrug his shoulders at me with an air of disappointment. Jim really cared about Baby M.

On Friday, Baby M's mom was discharged from the hospital. CPS informed her that Baby M was going to be taken into foster care, but the full impact of the news seemed to escape her and she left.

It was quiet in the nursery that Friday afternoon. It was getting late -- 5 p.m. -- and people were leaving for home and the weekend. The sun was growing dimmer over a spectacular 15th floor view of San Francisco and the only occupant in the newborn nursery was quiet little Baby M waiting to be picked up by the foster care program at 6 p.m. Her eyes were open, but she was silent, so I picked her up and rocked Baby M in my arms for a few minutes to say good-bye. As I thought about how all of the other babies in the ward had gone home with happy families and all of the love and opportunity that awaited these other babies -- tears started coming to my eyes thinking about how Baby M was left behind in the hands of strangers.

When Baby M's mom dramatically returned to the newborn nursery the next afternoon -- glassy tears streaming down her face because she couldn't find her baby in the Well Baby Nursery or anywhere in the hospital -- it was hard not to feel sorry for a mom wearing dirty tennis shoes with rolled down socks and a red sweatshirt who didn't realize -- like many of us -- what she had lost until it was truly gone.

The pager beeped and we dropped everything and ran to the labor and delivery room.

After a week of waiting, I finally witnessed my first newborn delivery. The mom was Rh negative and sensitized to Rh factor (which is sort of like seeing an ivory-billed woodpecker because everyone has read about it, but few people have seen such a case in the U.S. now that we are so meticulous about managing pregnant moms), and the baby was Rh positive.

The Ob-Gyn docs tried to pull the baby out using forceps, but baby wasn't coming out...so they took mom to the OR to do a C-section. I saw my first C-section, which was eerily how I imagined it. Save your romantic notions that surgery is a delicate scientific process...they made a transverse incision across mom's lower belly and reached in to grab the baby. There was a fair amount of blood, but it was fascinating how much of the blood was collected by a plastic bag around the incision (will learn more about this later, hopefully), and the tough Ob-Gyn ladies were pulling and rummaging around mom's belly looking for the blue baby. The pediatrics team generously allowed me to hold a blue sterile towel so that I could "catch" the baby. Soon we could see the head, and the Ob-Gyn attending reached in and pulled the baby out of the womb by its head. I held my arms outstretched, holding the blue cloth, ready to receive the baby from the Ob-Gyn docs, and the baby landed in my arms, newly severed from mom -- a big blue baby that was sort of floppy and doll-like. I carried the baby 3 feet to a warmer and we began warming, drying, and vigorously stimulating the baby with towels...he had Apgar scores of 3, 4, and 6.

The baby was taken to the ICN and I watched as the residents put in a central line. I mentioned that it was my first delivery, and one of the residents asked if I was keeping a journal of my third year of medical school. I told him no, but I do keep a blog...

Working in the Well Baby Nursery this week (or Hell Baby Nursery according to some interns who dislike the loads of paperwork, the MS3's LOVE the nursery) was a lot of fun. It was very pleasurable playing with newborns, they are so different from any other patients and a pleasure to care for. The parents are always very excited and grateful, and the dads are amusingly awkward and sort of dazed and eager to help. I learned how to perform a newborn exam, and what things to look out for and what findings are normal in a newborn.

Thursday, May 22, 2008

The silver-haired woman greeted me at the clinic door, one arm suspended in a bright blue sling.This wasn’t her first visit. In the preceding few months, she had come to the clinic twice with assorted aches and inexplicable pains. Now her husband had broken her arm, and the reason for those visits had become glaringly obvious: he had been hitting her.

And the domestic violence screening question I’d asked months before — nestled between queries about smoking and seat belts — seemed to have been spectacularly ineffective, since she’d answered “no.”

When I had asked about violence at home, I had been following guidelines set by the surgeon general and many professional groups, including the American Medical Association. Those who support routine questioning say domestic violence is as or more common in women than many diseases for which doctors regularly check, including breast and colon cancer, and its health risks are well documented.

Despite these recommendations, screening for domestic abuse in seemingly healthy women is nowhere near as widespread among doctors as testing for breast cancer or high cholesterol.Some physicians see domestic violence primarily as a criminal justice issue, and take umbrage at being expected to delve into a difficult, messy topic when they already have to screen for many other conditions and diagnose complicated diseases in the span of an ever-shorter visit.In a recent nationwide study of nearly 5,000 women, only 7 percent said a health professional had ever asked them about domestic or family violence. When surveyed, doctors often respond that they don’t ask such questions because of a lack of time, training and easy access to services that help these patients.

Some have reported that they worry about offending patients and believe asking won’t make any difference.

“Just like anybody else, doctors avoid things they may have discomfort doing,” said Dr. Michael Rodriguez, a researcher and family practitioner at the University of California, Los Angeles.

“There’s also an expectation on the part of some folks that once we identify abuse she should just walk away, and frustration when she doesn’t.”

Dr. Rodriguez and other experts say that urging an abused patient simply to leave may not be realistic or safe, for several reasons: The risk of being murdered is highest at the time one leaves, the woman may depend on her partner for food and shelter, and patients may not respond well to a doctor who dictates what to do.

They also say the best way to ask about such abuse is in a private place, with no family members present, as part of the routine patient history. If the patient says she has been battered or threatened at home, experts recommend that the doctor offer empathy, tell her what’s happening is wrong, document her story in the medical record and provide her with information on places to go or refer her to someone who may be able to help, like a social worker.Barbara Gerbert, director of the Center for Health Improvement and Prevention Studies at the University of California, San Francisco, said that while some women might deny domestic violence at first, the question itself could have a profound effect: many women remember that their doctor asked and eventually, even years later, reveal their secret.

“Just by asking, you may be planting a seed for change,” she said.

Numerous studies indicate that doctors ask about domestic violence poorly, however, and don’t handle it well when they do get a yes answer.

Felicia M. Frezell, 34, an office manager in Omaha, told me recently that she visited her doctor’s office many times with her five children during the 15 years she lived with her ex-husband, who was convicted in 2005 of raping her. She said that even though she often had bruises, no one ever asked her why — until she asked her doctor to look at her swollen black eye and told him her husband had hit her.

“He just said, ‘You’d better get out of that situation’ and left it at that,” Ms. Frezell said, and added: “Looking back, I didn’t know the resources that were out there. The doctor’s office is a good place to go because it’s neutral and it’s confidential. It’s not like telling your husband you’re going to the police department.”

According to the Bureau of Justice Statistics, from 2001 to 2005 (the last year for which statistics are available) there was an annual average of nearly 511,000 violent assaults against women — and 105,000 against men — by a spouse or intimate partner, about half resulting in physical injury.

Despite such numbers, the United States Preventive Services Task Force concluded in 2004 that although clinicians should “be alert” for signs of violence, there was insufficient evidence to recommend for or against screening asymptomatic patients for domestic abuse — mainly because of a dearth of large-scale scientific studies looking at this question.While many researchers say more money is needed to pay for such studies, some say the analogy to routine screening misses the point.

“Trying to equate it to a Pap smear is the wrong paradigm, and it’s just irrelevant,” said Dr. Christina Nicolaidis, a general internist and researcher at Oregon Health and Science University. “It’s not a test you can just check off.”

“The reasons to ask,” she continued, “are to educate a patient and to open the door so that the patient knows she can come to you. It’s part of developing a real relationship with your patient. Over time, you might be able to uncover the abuse and improve her safety, but you also might better understand why she’s having her symptoms and how to better approach her self-management of her illness.”

Abused women are at increased risk of chronic pain, depression, anxiety and alcohol and substance abuse, and they can have problems taking their medication correctly and getting to appointments. In one recent study, women who said they had been abused within the past year were more likely to have partners who interfered with their medical care.

Seven years ago, the Institute of Medicine, which advises the federal government, issued a major report on the training of health workers on family violence. The report concluded that such violence “was not a consistent priority” in health workers’ education and recommended that the Department of Health and Human Services establish education and research centers in family violence.

By unhappy coincidence, the report was unveiled at a news conference on Sept. 11, 2001, and has since “collected dust,” said one of the authors, Felicia Cohn, who now directs medical ethics at the University of California, Irvine.

“Certainly other issues took precedence at the time,” Dr. Cohn added, “but the continuing inattention is both inexcusable and embarrassing. This is a public health pandemic with immense health care implications.”

For my silver-haired patient — and other women I see at the clinic where I work — there have been no simple answers. I keep the telephone numbers for a local women’s shelter and the police department’s domestic violence unit in my lab coat pocket. And I keep asking the question, so my patients know there’s a place they can turn.

Erin N. Marcus is a general internist and associate medical director of the Institute for Women’s Health at the University of Miami Miller School of Medicine.

Monday, May 19, 2008

Just got back from the ED (for some reason, the med community calls it the ED, while the public calls it the ER or emergency room).

Pediatric urgent care was crazy busy today (everyone waits until Monday over the weekend), was there until 8 p.m. Then went over to the ED and saw the cutest 4 y/o boy with an eyelid laceration because his friend hit him in the eye with a rusty pole this afternoon (me: "it doesn't sound like he's a very good friend").

The cutest thing was when I was doing the neuro exam to make sure that his brain was intact after getting whacked in the head, and I asked him to do finger-to-nose to test his coordination.

Me: "Okay, I want you to touch your nose and then touch the tip of my finger."Boy: [Sticks his index finger up his nostril to the first knuckle and withdraws a snot-covered finger]Me: [Collective "Eew" arises from adults watching. Me pulling finger away quickly while parents burst out laughing] "Heh...okay...um, let's test your other finger..."

Thursday, May 15, 2008

In college, I was most interested in pediatrics because a) I like kids; b) I have 3 younger siblings whose ages range over a 12-year span; and c) most of my community service in high school and college reflected working with little kids or mentoring adolescents.

Feeling comfortable with babies, toddlers, preteens, teenagers has helped me enjoy my pediatric rotation, so it's funny how by the end of my year finishing clinical research at Stanford, my career interests had changed course and my interest in oncology grew. As a patient population, I really enjoyed working with an older age group of patients who had pancreatic cancer -- they had diverse backgrounds, interests, and personalities tied together by an unfortunate and often tragic illness.

One thing that worried me about pediatrics was the hearsay that it's not just the patient whom you have to worry about...but often their neurotic and demanding parents who are understandably worried about their most precious charges. Hearing that argument, I was turned off by the idea that maybe I could not treat the patient directly, but would spend much of my time negotiating diagnoses and treatments by proxy. Another common argument one often hears is that pediatrics can sometimes be "veterinary medicine" (I don't like this phrase), since nonverbal children cannot articulate their symptoms or discomfort.

During my pediatrics rotation, I have found that my worries about Parents (with a capital P) have been exaggerated. Although some Parents can be bossy, demanding, and overly histrionic, I have more often found myself touched by the love, dedication, and sacrifice that each parent demonstrates for his or her child. An infant who received a liver transplant practically lives in our inpatient ward with his parents and older brother, who spend every hour with him, sleeping on chairs and air mattresses every night and never leaving his side for days without a word of complaint or resentment. A mom who cries because her son has anorexia and will not eat anything she offers. Another mom asking about the cognitive effects of whole brain irradiation on her 10 y/o son with Down's syndrome and ALL. Parents who take showers in the hospital, sleep on chairs every night, pour every ounce of energy into supporting their children, no matter how sick the child is or how hopeless the situation may be.

So now I find that Parents tug at my heartstrings as much as their children do, and everything that I have always loved about kids remains the same. Children perceive the world differently, they are more pure of heart and have cute miniature body parts.

Adolescents are an interesting age group, too, they have such a unique set of concerns, risk factors, and half-formed perceptions of the world and how it should be. At best, their preoccupations and insecurities amuse and touch me, at worst, their teenage angst and myopic, self-conscious and self-centered views of the world impede effective medical care.

Overall, however, both pediatric patient groups demonstrate an acute vulnerability that makes me want to take care of them, and their little Parents too.

Wednesday, May 14, 2008

Today, I diagnosed a 16-month-old girl with acute otitis media. I am proud of this because a) the baby couldn't tell me what was hurting her and b) i've never seen an inflamed TM before. This makes me feel like maybe someday I can be a semi-competent doctor.

I also helped take care of a 10 y/o boy today who fell on his head and had a 2.5 cm. forehead laceration that was so deep it was down to the bone. It was a really wicked cool laceration, and the poor boy took it like a champ. Watching the suturing was so cool!

There was also a 4 y/o girl who also fell on the pavement, but she presented with waxing and waning mental status and 3 bouts of emesis in the exam room. We rushed her to the CT scanner in the emergency department to check her head.

Thursday, May 01, 2008

Four days of working at the inpatient pediatric ward at Parnassus (someone who works here a lot would be called "Little Miss Moffitt"!) and it feels like I've been here for TWO months!

Lessons learned from the wards so far:

1) Medical school may possibly be detrimental to your own health. A classmate observed that doctors spend so much time obsessing about other people (the patients) by talking about them for hours, measuring every mL of fluid that enters and leaves their bodies, writing about them, visiting them, that it's ironic how healthcare workers forgo the basic building blocks of life: eat, sleep, exercise, go outside for fresh air and sunlight.

3) Patients complain that they never see the doctor, but the doctor spends 10 hours everyday thinking about the patient, talking about the patient during rounds, making phone calls about the patient, writing orders for the patient, and writing progress notes for the patient...and then they spend 10 minutes interviewing and examining the patient!

4) Doctors can lose perspective by working the hospital everyday. Last night, we admitted a patient at 8 p.m., and after working for more than 12 hours...it didn't seem like anything new or exciting. But the family was really anxious because the patient was spending the night and it was all so unfamiliar and scary for them. Working in a hospital can give you a strange sort of myopia about what is normal and what is not...because everything normal at Moffitt is abnormal in the "real world."

I am loving my pediatrics rotation so far. Pediatricians are perhaps one of the nicest species of doctors, they are usually very happy and nurturing with a good sense of humor. I think it's impossible to be angry or bitter when you are surrounded by little children and adorable babies sitting in red plastic wagons pulled around the hallways or sitting at the nurses' station. Seriously, where else am I going to find a ward filled with red plastic wagons bearing adorable smiling kids (err...hooked up to IV's).

Yesterday, we had a talk on sickle cell anemia given by Dr. Mentzer (of Mentzer Index fame!). He is a professor emeritus at UCSF, and he talked about how he just grafted his pinot noir plants in the backyard.

Random Amusing Quotes:

Me: I don't even know how UCare works!Intern: It barely does.

Me: [An 11 year-old boy] urinated on himself this morning and he became really embarassed and started to cry.Attending: Happens to the best of us.[Really?]